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Neck and Back Pain I. II. III. IV. Strains a. Back strains will present predominantly in the paracervical or paralumbar areas (muscle) b. The pain will not generally radiate or be associated with paresthesias c. Diagnosis i. X-ray is not necessary for diagnosis ii. History and physical 1. Patient will probably not have decreased reflexes or positive straight leg raising test d. Treatment i. Conservative is key- ice/heat, NSAIDs ii. Patient should respond in 4-6 weeks 1. If they do not have a good response then x-rays and MRI may be necessary Herniations a. Patient will point directly to the spine where the patient herniated the disc i. May have muscular pain as well b. Pain will radiate throughout the determine and complain of paresthesias c. Usually occurs at L4-S1- where the concavities and convexities change (increased pressures) d. Diagnosis i. History and physical- palpate and ROM (probably restricted) 1. Observation of the patient sitting and moving are important 2. Spurling test- compression of the head and rotation will mimic symptoms of herniation 3. Reflexes- may have decreased reflexes 4. Straight leg raising- pain on straight leg raising in back is positive a. Must specify degree of leg flexion ii. Not typically X-rayed first visit (unless red flag patient) e. Treatment i. Conservative treatment first- therapy, anti-inflammatory, pain medications ii. Epidural injections- steroid injection at the level of the herniation 1. 2-3 injections are necessary iii. Neurosurgical consult- Discectomy with possible laminectomy Spinal Stenosis a. Typical presentation- pain that begins after walking for awhile (not at the beginning) i. It will be described as a bilateral burning pain moving down the legs ii. Patient will state that they need to stop and bend forward to feel better 1. Opens posterior column and temporarily relieves stenosis b. Usually occurs at L4-S1- where the concavities and convexities change (increased pressures) c. Diagnosis i. X-rayed on first visit- usually caused by a bony block (arthritis, decreased disc height) 1. Many elderly patients will present with preexisting scoliosis d. Treatment i. Physical therapy- not usually effective ii. Neurosurgery referral Compression Fractures a. Patient will present with severe pain of fast onset i. Pain is constantly present b. Usually at the level of T10 c. Diagnosis i. History and Physical- restricted ROM, no decreased DTRs ii. X-ray- will show compression fracture d. Treatment i. Pain medication ii. Treat underlying osteoporosis- bone densities, endocrinology screen 1. 1400 mg of calcium per day 3. Fosamax or Actonel 2. 400 IU of vitamin D per day 4. Weight bearing exercise iii. If patient doesn’t respond to treatment you must think of multiple myeloma 1. CBC with diff., Benz-Jones protein, X-ray V. Ankylosing Spondylitis a. Age 20-40 year old male b. Presents with pain and stiffness i. Pain radiates to large joints- shoulder and pelvis ii. Tight hamstrings c. Diagnosis i. X-ray- bamboo spine d. Treatment i. DMARDs, NSAIDs, physical therapy VI. Cauda Equina Syndrome a. Dissemination or fibrosis of the distal spinal cord b. Patient presents is a progressive manner with pain, loss of motor function, difficulty urinating/defecating c. Most lethal diagnosis in orthopedics but extremely unlikely d. Seen in motor vehicle accidents e. Treatment i. Surgical emergency- success rate is low VII. Metastatic Disease a. Boring night pain not relieved by anything b. The patient is a “red flag” c. Diagnosis i. X-ray immediately iii. MRI ii. Bone scan d. Treatment i. Treat the cancer fast VIII. Osteoarthritis a. Progressive development of pain i. Most commonly knees- but can be nearly any joint b. Pain worsens with ambulation and is associated with crepitus on movement c. Motion will become progressively restricted d. Must ask the question- How many blocks can you walk before it hurts? i. Have you become more of a house dweller? ii. Can you perform ADLs without difficulty? iii. All three questions must be documented to justify total joint replacement e. Diagnosis i. Physical exam- will show an antalgic gait on the affected side (remove socks and shoes) 1. ROM must be documented IX. X. 2. Measure leg length ii. X-ray f. Treatment i. Patient should use a cane in the opposite side of the affected joint ii. Conservative 1. Physical therapy and pain medications prn 2. Intraarticular injections- pseudo synovium a. Hyaluronic acid preparation b. Helps decrease pain but is transient iii. Total joint replacement- hip or knee 1. Only known treatment to cure joint arthritis 2. New joint does have a shelf-life Scoliosis a. Tends to occur in juvenile population with female predilection b. It is a curvature and a rotation of the spine c. Idiopathic is the most common cause d. Curve tends to increase during puberty e. Diagnosis i. Must ask females if menstruation began ii. Must ask males about secondary sex characteristics iii. May have winged scapula or rotated/tilted pelvis iv. Have patient bend forward and observe scapula- use scoliometer (not specific enough for Dx) v. X-ray or the entire spine- scoliosis series 1. Must measure the Cobb’s angle 2. Upper-most vertebrae and lower-most vertebrae that is most curved and draw a line perpendicular to the curves a. Were they intersect is were you measure b. 20 degrees or less- watch c. Over 20 degrees- referral to pediatric spine physician vi. Most patients won’t have pain with the scoliosis f. Treatment i. Mild curves- bracing ii. Progressive curves- intraoperative fusion iii. Under 20 degree Cobb angle with systemic symptoms will be deferred to specialist OVERALL TREATMENT- LOSE WEIGHT, JOIN WEIGHT REDUCTION PLAN!!!!!!!!!!!!!!!!!! Scoliosis I. Scoliosis a. Lateral curvature of the spine b. Idiopathic (unknown cause) vs. known cause c. Known causes i. Neuropathic 1. Spinal cord injury 4. Syringomyelia 2. Poliomyelitis 5. Myelomeningocele 3. Progressive neurological disorders 6. Cerebral palsy ii. Myopathic 1. Arthrogryposis 2. Muscular dystrophy iii. Neurofibromatosis iv. Congenital d. Idiopathic: most common i. Infantile: <3y.o., juvenile 4-10 y.o., adolescent <16 y.o.- first diagnosed ii. Resolving vs. progressive curves 1. Infantilea. measure RVA (rib-vertebral angle); draw a line perpendicular to apical vertebral endplate; another from midneck to midhead of corresponding rib; RVAD difference between angles on concave and convex sides b. Angle measures >20 degrees= progressive c. Curves <20 examine and x-ray q 4-6 mos d. Curves >20 brace or short fusion 2. Juvenilea. 15% of all patients b. Multiple curves can occur c. Convexity of the thoracic curve to the right usually d. Treatment: <20% observe with standing pa x-rays q 4-6 mos 3. Adolescent a. Overall ratio girls 3.6:1 b. Exam= physical, neuro exam, back exam, PA x-rays (iliac crest to most of C-spine) lats c. Cobb Angle i. Locate superior end vertebra ii. Locate inferior end vertebra iii. Draw intersecting perpendiculars from these vertebra iv. Angle of deviation is the angle of the curve v. End vertebras tilt the most d. Position of the pedicles on PA x-ray indicates degree of rotation e. Curves i. Single major lumbar= most benign ii. Single major thoracolumbar iii. Combined thoracic and lumbar= double major= most common iv. Single major thoracic v. Cervicothoracic= rare vi. Double major thoracic f. Treatment i. Curves <20% in skeletally immature should be examined q 6 mos ii. Curves <20% in skeletally mature no follow up iii. Curves >20% in skeletally immature, x-rays q 3-4 mos with Orthosis for progression beyond 25% iv. Curves of 30-40% in skeletally mature x-rays q year for 2-3 years v. Orthosis, fusions II. Osteoarthritis a. Osteoarthritis is estimated to affect more than 20.7 million people in the US b. OA= noninflammatory disease characterized by variable progressive degeneration of joint cartilage with bone margin involvement and osteophyte formation c. Women>men after 4th decade d. Targets hips and knees, and MCPs, PIPs, DIPs of the hand, shoulder spine- can occur in any joint e. Risk factors: i. Obesity v. Developmental abnormals ii. Genetics vi. Repetitive motions- sports, job iii. Trauma vii. Quadriceps muscle weakness iv. >40y.o. III. OA develops normal joint cartilage under abnormal load or sues OR in abnormal cartilage under normal load or use IV. Progression involves a. Joint cartilage degeneration d. Thickened joint capsule b. Synovial hypertrophy e. Osteophyte formation c. Sclerosis of subchondral bone f. Cyst formation in the bone V. Evidence points to biochemical factors in progression: cartilage matrix degeneration secondary to destruction by cytokines, enzymes, and release of nitric oxide. Insufficient Hyaluronic acid in synovial fluid diminishes fluid viscosity, reducing joint cushion VI. Signs and symptoms of OA noted only in involved joints a. Severity depends on degree of deterioration f. Crepitus with ROM b. Early= AM stiffness improves with motion g. Acute synovitis= red, swollen, painful, c. Pain, decreased mobility, altered gait “hot” d. Heberden’s nodes= osteophytes DIP h. Depression as secondary reaction e. Bouchard’s nodes= osteophytes PIP VII. Diagnostic tools a. X-rays= primary i. Joint space narrowing ii. Changes in subchondral bone- sclerosis iii. Osteophytes b. Labs for differential diagnosis i. ESR, CRP, Lyme, ANA, RF VIII. Differential Diagnosis a. Hypertrophic oseoarthropathy e. Pigmented villonodular synovitis b. Neuropathic arthropathy f. Inflammation c. Osteochondritis dissecans g. Trauma d. Osteochondromatosis IX. Treatment: pain relief that will restore or maintain patients ability to move freely and possibly slow the disease process a. Non-pharmacologic i. Evaluate ADL’s ii. Social support- maintain independence iii. Patient education iv. Exercise- strengthen muscle, prevent or minimize stiffness, improve ROM v. Weight reduction vi. Nutritional counseling- improve immune system vii. Use of assistive or orthotic devices- cane, walker, “grabber” b. Pharmacological i. Acetaminophen ii. Nonsteroidal anti-inflammatory agent (NSAIDs) iii. Cyclooxygenase-2 inhibitor (COX-2) iv. Glucosamine 1500mg/chondroitin sulfate 1200mg- use with caution in diabetic patients v. Effusion= aspiration followed by injection of 1% lidocaine without epi; 20-40 mg Triamcinolone hexacetonide in a 1:2 ratio vi. Intra-articular visco-supplementation: uncompartmental disease 1. Hylan G-F 20 (Synvisc) 3. Suprax 2. Hyaluronate sodium (Hyalgan) c. Surgery i. Arthroscopy- remove abnormal cartilage and postpone TJA ii. Arthroplasty- only curative treatment Evaluation of Back Pain I. II. III. IV. Functions of the spine: upright posture; allows motion in many planes; shock absorber; protects the neural elements; muscle/ligament attachments; anchors the protective ribs; active bone marrow; calcium bank Anatomy a. Bony i. Ribs/stability b. Ligamentous ii. Kyphosis c. Cervical e. Lumbar i. Motion i. Large discs ii. Lordosis ii. Large vertebrae d. Thoracic iii. The problem area Evaluation a. History: listen c. Plain x-rays b. Physical examination d. CAT scan (cortical bone) i. Inspection e. MRI (marrow; soft parts) ii. Musculoskeletal f. Bone scan iii. Neural g. Blood studies h. Myelogram Non-traumatic Back Pain a. Acute b. Chronic c. 75% is benign and mechanical- respond to rest; analgesics; anti-inflammatory meds; relaxants; heat; moderation of activity d. Beware in children and elderly i. Elderly 1. Osteoporosis 2. Degenerative arthritis 3. Multiple myeloma 4. metastatic disease a. Breast, lung, prostate, thyroid, kidney 5. Infection e. Bad symptoms are: night pain, boring quality; does not improve; other symptoms such as weight loss, malaise, cough, symptoms related to the primary i. Children 1. Infection 6. neural tumor (glioma) 2. Bony tumor 7. Soft tissue tumor (lipoma) 3. Spondylolisthesis 8. Idiopathic scoliosis is not 4. Neural tumor painful 5. Spondylolisthesis